In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD

Danish Air Ambulance/HEMS Denmark In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Danish Air Ambulance/HEMS Denmark Three bases in Skive, Billund and Ringsted 3-crew concept: DOC, pilot, HEMS Crew member Airbus EC-135 P2+ VFR/IFR/NVG/PINS 24/7/365 In average 3 mission/base/day 2 RBC and 2 plasma on board

Severe blunt truncal injuries, male 24 yrs old In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report x 24  Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Severe blunt truncal injuries, male 24 yrs old Remote location, 104 NM distance, fuel considerations/options Damage Control Rescuscitation initiated before HEMS arrival FAST & X-rays: massive bleeding, multiple injuries, pelvic fracture, head trauma 2 chest tubes, pelvic sling, multiple IV lines, CVC, a-line Medical ambition: Transfer to Level 1 Trauma Centre

In-flight, 50 mins flying time: 7 RBC 4 plasma 1 l Albumin In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Before HEMS take-off: 5 RBC 2 l Albumin 3,5 l crystalloid TXA 2 g In-flight, 50 mins flying time: 7 RBC 4 plasma 1 l Albumin 2,5 l crystalloid 2 pressure perfusors Golden Hour Container SBT 60-80 Spontaneous breathing on ET tube, ETCO2 5.0-6-0, RF 8-10/min S-Ketamine, Fentayl, Noradrenalin 0.20-0.50 microg/kg/min

2 platelet concentrates (4 donors) TXA 2 g In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD In Trauma Centre: 13 RBC 13 plasma 2 platelet concentrates (4 donors) TXA 2 g Damage Control laparotomy/thoracotomy Injuries were deemed unsurvivable and further treatment futile

On arrival in Trauma Centre: Coagulopathy: INR 1,7 In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD On arrival in Trauma Centre: Coagulopathy: INR 1,7 TEG: decreased platelet/fibrinogen function

Massive in-flight rescuscitation of blood products is feasible In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Conclusions: Massive in-flight rescuscitation of blood products is feasible Damage Control Rescuscitation aiming at 1:1:1 of RBC, plasma and platelets should be prioritized to avoid dilution and further coagulopathy On-board blood products optimally shoud consist of all three since local hospital transfusion support is scarce

2. Effect of plasma in prehospital phase – Randomized Controlled Trial In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Discussion: Feasiblility of prehospital Damage Control Rescuscitation is demonstrated How can we improve: 1. Platelet function: evaluation in the prehospital phase and on arrival in hospital. 2. Effect of plasma in prehospital phase – Randomized Controlled Trial 3. Effect of prehospital platelet transfusion – Randomized Controlled Trial

Recent/current studies on the way: In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Discussion: Recent/current studies on the way: PATCH TRIAL – TXA study from Australia. Recap of CRASH2 but starting in the prehospital phase Prehospital Administration of Tranexamic Acid i Trauma Patients Crit Care 2016 20:143. Wafaisade et al. Significantly improved early survival , prolonged time to death, the more injured, the better the effect of TXA, recommends first dose of TXA en route to hospital

Recent/current studies on the way: In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD Discussion: Recent/current studies on the way: RePHILL – Resuscitation with Prehospital Blood Products Randomization between crystalloid 1 l 0.9% saline or 2 RBCs + 2 Plasma to traumatic injury resulting in hemorrhage HEMS setting in Austria very similar to Danish Air Ambulance/HEMS Denmark Fibrinogen concentrate in trauma patients, presumed to bleed Fries et al Severely traumatized patients with visible significant and/orclinical signs of severe bleeding are randomized to either placebo or Fibrinogen according to weight. HEMS/Physician Manned Ambulance setting in Austria and Germany

In-flight Damage Control Resuscitation of massive bleeding – challenges and opportunities during long flights. A Case Report   Peter Martin Hansen, MD, Jakob Stensballe, MD, PhD THANK YOU – FLY SAFE